Medical History and Consent to Treat

Medical History and Consent to Treat

Initial intake form for Chadoux Beauty for treatment.
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Date*

MonthDayYear
Date
Have you used any Retinol products within the past week? **If you have used Retinova, Retin-a, Accutane or any prescribed medication in the past 3 months please select yes. receiving waxing, chemical peels, or exfoliation treatments while using these drugs can, and will cause great damage to the epidermis. If you are using any of these prescription drugs and choose to select 'no' and continue with the service Chadoux Beauty and all of its Subsidiaries, contractors, or employees will not be held liable for any damages caused.*

yesno
Have you been waxed before?*

yesno
If yes, when and what areas have you waxed?
Have you received a chemical exfoliation treatment in the past 7 days?*

yesno
If yes, what type? (chemical peel, enzyme, etc.)
Have you received lash extentions before?*

yesno
If yes, when and what type?
Are you allergic to any lash adhesives, tapes or hydragel patches?*

yesno
If yes, what type, and what type of reaction do you get?
Have you tinted your lashes before*

yesno
If yes, what color?
Have you tinted your brows before*

yesno
If yes, what color?
Have you received a lash lift or brow lamination before*

yesno
If yes, when?
Have you received any permanent makeup before?*

yesno
If yes, what type of permanent make up, and how long ago??
Have you received a facial, vajacial, or back treatment before?*

yesno
If yes, when and where?
Have you applied any topical AHA, BHA, lightining or bleaching gels? ?*

yesno
If yes, when and where?
Have you had microdermabrasion, laser resurfacing, light therapy, or injectable treatments?*

yesno
If yes, when and where?
Have you had continuous sun exposure, shaved, scrubbed, or expereanced any peeling in the last 48 hours*

yesno
Are you currently pregnant or lactating?*

yesno
If yes, Who is your dermatologist and what are you seeing them for?
Are you currently taking any prescription drugs?*

yesno
If yes, What medicine are you taking? ** this is to insure there are no contraindications**
Do you have any allergies? If so please list them.*
What service are you receiving today? or would you you like to receive today?*

WaxingLashesFacialBack TreatmentConsult only
Do you have a history of any of the following*

diabeteshypo/hyper tensionlupuscancerpsoriasiseczemarosaceatelangiectasiasun burnscystic acnefaintingcold sores/ blistersHIV/AIDSSTI'sHepatitisVaricose VeinsIngrown HairCystsWarts/Boils
Check any of the following if they apply to you*

Caffeine drinker (coffee, teas, sodas, etc.)medicationsuse facial cleanseruse facial exfoliantuses body soapuses body exfoliantuses SPFuses facial serumbruise easilyshaves regularlywaxes regularlyreceives laser hair removalregularly takes pain medications (Tylenol, Ibuprofen, Advil, Motrin, etc..)other
Reservation Policys:

All reservations are secured via credit or debit card to hold the reservstion spot. If a card is not placed on file then the reservation can only be made by pre-paying 100% for the reservation.

If guest decides to pre-pay for reservation cancelation policy still remains and the reservation may be moved if its greater than 24 hours in advance. If the reservation is within 24 hours there will still be a 50% retainer taken out of the cost of the service and the remaining 50% will go towards future reservation.

Cancelation Policy:

If you cancel your reservation more than 24 hours in advance there will be no fees associated with the cancelation

If you cancel your reservation within 24 hours of your reservation time you will be charges a 50% retainer fee for your reservation automatically. If the retainer isnt paid you will no longer be able to recieve services from Chadoux Beauty.

No Show Policy:

First No-Show: If you no- show your reservation you will be charged a 75% retainer fee for the reservation automatically. If the retainer isnt paid you will no longer be able to recieve services from Chadoux beauty.

Second No-Show: If you no-show your reservation a second time you will be charged a 75% retainer fee for the reservation. If the retainer isnt paid you will no longer be able to recieve services from Chadoux Beauty. If guest decided to book another reservation pre-payment of 100% of the cost of services will be required and will be non-refundable in case of no-show or cancelation within 24 hours.

Third No-Show: if you no-show your reservation a third time you will be blocked from making a reservation within 366 days of booked reservation. After 366 days the guest may book another reservation and will start over with Chadoux Beauty.
Have you read and agreed to the reservation policies, cancelation policies, and no-show policy?*
Disclaimers and Liability disclosure

Receiving a service from a Chadoux Beauty is an at will service. Chadoux Beauty will never force, coerce, or intimate anyone into receiving a service. Chadoux Beauty will conduct consultations to ensure that any treatment given is safe for the guest to the best of their abilities. Chadoux Beauty cannot and will not be held responsible for any reactions that happen due to dishonesty on the intake form, or for reactions caused by natural circumstances that are not due to negligence. Chadoux Beauty has the right to refuse service from anyone at any time for any reason.

By signing this form you are acknowledging that you have read this from and have provided the most accurate answers to the screening questions. You have released Chadoux Beauty, and its subsidiaries from any liabilities from any treatments received on signed dates below. You understand that Chadoux Beauty and its subsidiaries will provide the best service to their abilities, and will not cause intentional harm. You understand that there are potential side effects with any treatment received and that Chadoux beauty and its subsidiaries will go over that information with me.
Treatment of Minors:

Chadoux Beauty will provide services for minors (persons under 18 years of age). Minors must be accompanied by an adult guardian during the treatment.
Please upload a picture of your ID. This insures the safety of all guests of Chadoux Beauty. *

Cancelof
Have you read and understand the Disclaimers and Liabilities and the Treatment of minors*
Signature*
Are you currently seeing a dermatologist?

yesno
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